Healthcare Provider Details

I. General information

NPI: 1326319013
Provider Name (Legal Business Name): MICHELLE S. MIX FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE SANDERS FNP-BC

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7320 SHALLOWFORD RD STE B ATTN: PROVIDER ENROLLMENT
CHATTANOOGA TN
37421-2626
US

IV. Provider business mailing address

7320 SHALLOWFORD RD STE B ATTN: PROVIDER ENROLLMENT
CHATTANOOGA TN
37421-2626
US

V. Phone/Fax

Practice location:
  • Phone: 423-648-6483
  • Fax: 423-648-6497
Mailing address:
  • Phone: 423-648-6483
  • Fax: 423-648-6497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 204496-7
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19827
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: